What Do We Mean By Integrated Care, Whole Person Care, Transmural Care, Or Coordinated Care?
The buzzword in health policy these days is “integrated care.” Also known as whole person care, transmural care, coordinated care, collaborative care, or holistic care, the basic premise is that integrated health care is the systematic coordination of mental health care with physical health care.1 Generally speaking, this means aligning behavioral health care – care for such disease states such as depression, schizophrenia, autism, or addiction treatments – with primary health care – care for broken bones, chronic conditions like diabetes and heart disease, or seasonal flus. More than just mental health and primary care services, some whole person care programs are experimenting with adding additional health services such as dentistry, optometry, pharmacy, and smoking cessation programs.2
Combining mental health and primary care seems so obvious now, how did it ever become separate in the first place? For many years, the prevailing theory was that physicians handled the organic elements of disease while the psychosocial elements of care were handled by other providers.3 4 Then in the 1980s and early 1990s, population health researchers began to document that many of the individuals who came to primary care physicians for care were identified as having major depression.
They found those individuals with major depression were more likely to have high numbers of medically unexplained symptoms, more comorbid illnesses, more functional impairment compared to others with comorbid illnesses like diabetes and heart disease. These individuals typically used twice as many health care services as their counterparts, costing insurers twice as much in resources. Studies during this time showed only a quarter to half of patients with depression were accurately diagnosed by these primary care physicians. Even if the individuals were accurately diagnosed, most of those patients did not receive the proper amount of prescribed psychotherapy or pharmacotherapy from their primary care doctors, causing many suffering individuals to discontinue therapies within the first few weeks, and never complete a referral to see a mental health provider.5
These gaps in care between primary care and behavioral health are often more pronounced among minority populations and individuals living in poverty, two key demographics that already lack access to quality mental health services. The overarching goal of integrated care is that uniting behavioral health and primary care will enhance quality of care and quality of life and increase consumer satisfaction. And this, in turn, will help improve efficiency within the health system to ensure more patients receive the care they need, when and where they need it.6
Integrated care can make a big difference for patients with comorbidities as they can have their health needs met by a central provider organization that has all many services available instead of having to make appointments with different specialists all over town.7 8 This care is especially important for individuals in marginalized communities who lack access to specialty care or reliable transportation, such as rural or tribal populations. Collaborative care has been offered for many years through providers such as the Veterans Administration and Kaiser Permanente, but it is now being expanded to serve more Americans, thanks to the encouragement of government grants and value-based reimbursement that aim to pay providers for keeping patients healthy instead of the traditional fee-for-service model.9
A November 2020 survey of behavioral health and intellectual development and disability provider organizations found that more than half (52%) of providers surveyed say they have already started the process of integrating behavioral health and primary care. A third of provider organizations (33%) indicated they are considering integrating behavioral health and primary care, while 15% of provider organizations said they are not considering an integration initiative currently.10
Of the organizations that are already begun integrating services, many have chosen established designations to guide their efforts. About a quarter of providers (23%) said they are considering, or already pursuing, designation as a Federally Qualified Health Clinic (FQHC) or Look-Alike (LAL) while 30% are considering, or already pursuing, designation as a Certified Community Behavioral Health Clinic (CCBHC). Meanwhile, about 14% of providers surveyed said they are considering, or already pursuing, designation as a Patient Centered Medical Home (PCMH).11
These care coordination models are not the only ones available. A 2019 report found there are about seven main models providers use to integrate physical and behavioral health. The models range from those that change provider roles within the existing system such as PCMH, health homes, and CCBHCs to models that restructure the basic financing of benefits like accountable care organizations (ACOs), managed long-term services and supports (MLTSS) plans, dual-eligible integration initiatives, and vertical/specialty health plans.12 While each of these designations share a common goal of bringing high-quality comprehensive care to underserved populations where access to care is often a challenge due to financial, transportation, language, or cultural barriers – the requirements and benefits for each vary, often based on the organization that granted the initial funding.13 Many of these collaborative care programs can be excellent safety net providers as they often offer services regardless of the patient’s insurance status, citizenship, or ability to pay.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is furthering integrated care by funding CCHBC expansion grants. In January 2020, SAMHSA offered $197 million in annual funding to help providers combine behavioral health services with physical health services. The total funding per award was up to $2 million per year for up to two years. 14 Then in January 2021, the federal COVID relief bill included $4.25 billion to SAMHSA to address mental health concerns. Of those funds, $600 million was ear marked for CCHBC grants.15
Similarly in July 2021, the Health Resources & Services Administration (HRSA) awarded nearly $143.8 million in American Rescue Plan (ARP) Act funding to 102 FQHC program look-alikes (LALs). The receiving organizations were tasked with using the one-time funding ranging from $500,000 to more than $11.7 million to respond to and mitigate the spread of coronavirus disease 2019 (COVID-19), and to enhance health care services and infrastructure in their communities. Each LAL is a community-based health care provider organization that, like an FQHC, provides primary health care services to underserved communities and vulnerable populations.16
References:
1 Trends in Behavioral Health: Third Edition. (August 2021). Retrieved from https://psychu.org/guide-third-edition/.
2 Egan Bennett K. & Bowles S. (2021, April 21). Where Are We On the Road to Integration Of Physical & Behavioral Health? Retrieved December 11, 2021, from https://integratedcareonline.com/where-are-we-on-the-road-to-integration-of-physical-behavioral-health-care/.
3 Rabinowitz, B. Healthcare is Making Progress on the “Social” in the Biopsychosocial Model. (2020, June 29). NextGen Advisors. Retrieved December 8, 2021, from https://www.nextgen.com/blog/progress-biopsychosocial-model.
4 Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977 Apr 8;196(4286):129-36. doi: 10.1126/science.847460. PMID: 847460.
5 Katon, W., Unützer, J., Wells, K., & Jones, L. (2010). Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. General Hospital Psychiatry, 32(5), 456–464. https://doi.org/10.1016/j.genhosppsych.2010.04.001.
6 World Health Organization (October 2016). Integrated Care Models: An Overview. Retrieved December 8, 2021, from https://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf.
7 Intentional Approaches to Integrated Care: Results of a 2020 National Survey of Behavioral Health and Intellectual and Development Disability Providers with Case Studies. (2021, February 10). Retrieved from https://integratedcareonline.com/intentional-approaches-to-integrated-care/.
8 Sandhu, S., Sharma, A., Cholera, R., & Bettger, J. P. (2021). Integrated Health and Social Care in the United States: A Decade of Policy Progress. International journal of integrated care, 21(4), 9. https://doi.org/10.5334/ijic.5687
9 Katon, W., Unützer, J., Wells, K., & Jones, L. (2010). Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. General Hospital Psychiatry, 32(5), 456–464. https://doi.org/10.1016/j.genhosppsych.2010.04.001.
10 Intentional Approaches to Integrated Care: Results of a 2020 National Survey of Behavioral Health and Intellectual and Development Disability Providers with Case Studies. (2021, February 10). Retrieved from https://integratedcareonline.com/intentional-approaches-to-integrated-care/.
11 Intentional Approaches to Integrated Care: Results of a 2020 National Survey of Behavioral Health and Intellectual and Development Disability Providers with Case Studies. (2021, February 10). Retrieved from https://integratedcareonline.com/intentional-approaches-to-integrated-care/.
12 Mandros, A. (2019, November 25). The Medicaid care Coordination models driving strategy in your state. Retrieved May 06, 2021, from https://openminds.com/market-intelligence/executive-briefings/the-medicaid-care-coordination-models-driving-strategy-in-your-state/
13 Alphabet Soup of Integrated Care: Understanding FQHC, FQHC Look-Alikes, CCBHC
14 SAMHSA accepting applications for CCBHC Expansion Grants. (2020, March 05). Retrieved May 06, 2021, from https://openminds.com/market-intelligence/news/samhsa-accepting-applications-for-ccbhc-expansion-grants/
15 COVID relief bill Provides SAMHSA $4.25 billion for behavioral health. (2021, January 29). Retrieved May 06, 2021, from https://openminds.com/market-intelligence/news/covid-relief-bill-provides-samhsa-4-25-billion-to-provide-increased-behavioral-health-services/
16 HRSA Awards Nearly $144 Million to 102 FQHC Look-Alikes. (2021, August 9). https://openminds.com/market-intelligence/news/hrsa-awards-nearly-144-million-to-102-fqhc-look-alikes/
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